MCC Health Inquiry Form 健康詢問表格
Email address *
Date 日期
MM
/
DD
/
YYYY
Name 名
Your answer
Are You Microcard2u Member 是否微卡會員
Date Of Birth 生日
MM
/
DD
/
YYYY
Age 歲数
Your answer
Heart Attack 心臟病
Heart Attack 心臟病
Your answer
Stroke 中風
Total cholesterol 总胆固醇
Your answer
Triglyceride 甘油三酯
Your answer
High density lipoprotein (HDL) 高密度脂蛋白
Your answer
Low density lipoprotein (LDL) 低密度脂蛋白
Your answer
Diabetes 糖尿病
Diabetes 糖尿病
Your answer
Family Diabetes History
Blood Sugar Level 血糖值Normal - after meals 正常-餐后
Your answer
Blood Sugar Level 血糖值 Normal - Fasting 正常-空腹
Your answer
Current Diabetes Prescription 目前糖尿病藥方
Your answer
Hypertension 高血壓
Hypertension 高血壓
Your answer
Blood Pressure Average 血壓平勻数 High Pressure 高壓
Blood Pressure Average 血壓平勻数 Low Pressure 低壓
Other illness 其它病症
Other illness 其它病症
Your answer
General Info 基本信息
The illness begins 病症開始于
Your answer
Occupation 職業
Your answer
Working Hour 工作時间
Your answer
Remarks 備注
Your answer
This information is only used by the health advisor team formed by microcard2u and the physician. It will not be made public or rumored. The name filled in above is not important. The applicant has the right not to fill in the full name, but must fill in the email because microcard2u only answers by email. 此資料只供給微卡內部及醫師所组成的健康顾问团队所用, 將不會公開給大眾或外傳. 以上所填寫之姓名並不重要, 申請者有權不填寫全名, 但必需填寫电郵, 因為微卡只以电郵方式作答.
Providing more information will enable us to make more accurate judgments for our team of health experts and health consultants. If possible please email your medical report to microcardmarketing@gmail.com 提供更多的資料, 將能為我們的蜂學專家和醫師所组成的健康顾问团队作出更準確的判斷. 如果可能,请将您的医疗报告发送至 microcardmarketing@gmail.com
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